GW1--06932_Well Construction - GW1_20241119

. Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
George Brown III 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 180 ft 200 30 GPM
4654-A ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for mold-cased wells)OR LINER(If ap licable)
Rowan well Drilling PROM TO DIAMETER THICKNESS MATERIAL
0 ft. 32 ft. 61/4 In. SDR21 PVC
Company Name 418662
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. ill
ft
3.Well Use(check well use): ft In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSI2Z THICKNESS MATERIAL
Agricultural '©Municipal/Public 0 tit, fw in.
Geothermal(Heating/Cooling Supply) EllResidential Water Supply(single) ft. ft In.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Holeplug Gravity 10
Monitoring 'Recovery ft. ft.
Injection Well:
ft ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft.
Experimental Technology DSubsidence Control ft ft. i
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sotrock type,grain acre,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 15 dirt
4.Date Well(s)Completed:10/29/24 ID Well #418662 15 fr. 32 fI. solid rock
5a.Well Location: ft ft. 1
Ralfael Delgado ft. ft.
Facility/Owner Name Facility iD#(if applicable) ft ft. z R '�:i', ::3 '..
275 Alan Circle, Salisbury NOV 1 cd 2624
Physical Address,City,and Zip
Rowan 472A023 21.REMARKS Ir':_:.- _; ,--
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwell field,one iat/iong is sufficient) 2 Certification: I /
35 624775 80 551596 Jam' ;
N w V' t E i2�1 2�
6.Is(are)the well(s)iPeranent or Temporary Signature of Certified We Contractor i Date
nt
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IN Yes or )No with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
wed'i SUBMITTAL INSTRUCTIONS i
9.Total well depth below land surface:225 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3@.200'and 2Q100) construction to the following: i
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of this'form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) ` i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)30 Method of test:weir 24c.For Water Supply&Iniectio Wells: In addition to sending the form to
the address(es) above, also submit!one copy of this form within 30 days of
13b.Disinfection type:chlorine Amount: 9 OZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i + Revised 2-22-2016